MEDICAL POLICY No. 91326-R5 VARICOSE VEIN TREATMENT:

MEDICAL POLICY
No. 91326-R5
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal Radiofrequency Ablation and Sclerotherapy
Effective Date: June 7, 2012
Date of Origin: March 19, 1990
I.
Review Dates: 1/93, 2/95, 12/99, 12/01, 6/02, 6/03,
12/03, 11/04, 10/05, 10/06, 6/07, 6/08, 6/09, 6/10,
10/10, 10/11, 10/12, 10/13
Status: Current
POLICY/CRITERIA
A. Varicose vein treatment is a covered benefit when medically necessary as outlined
below. The treatment of spider veins or telangiectasis of the lower extremities is
considered cosmetic and is not a covered benefit.
B. Limits/Indications
1. Treatment of varicose veins is covered when ALL of the following exists:
a. The patient is symptomatic and has one or more of the following:
• Documented history of complications of venous stasis (dermatitis,
ulceration, subcutaneous induration);
• History of hemorrhage of large varicosities;
• Significant leg aching, heaviness, or cramps and/or swelling during
activity or after prolonged standing, severe enough to impair mobility;
• Recurrent episodes of superficial phlebitis in the affected area;
• Refractory dependent edema due to the varicosities
b. A three-month trial of conservative therapy such as exercise, periodic
leg elevation, weight loss, compressive therapy, and avoidance of
prolonged immobility where appropriate, has failed.
c. Maximum vein diameter of 20 mm for ERFA or 30 mm for EVLT.
d. Absence of thrombosis or significant vein tortuosity, which would
impair catheter advancement.
e. Absence of significant peripheral arterial diseases.
2. The following procedures are covered:
a. Excision
b. Ligation
c. Stab phlebectomy
d. Sclerotherapy
e. Endoluminal radiofrequency ablation (ERFA or VNUS) of greater or lesser
saphenous vein, if ultrasound shows evidence of venous reflux
f. Endovenous Laser Therapy (EVLT) or greater and/or lesser saphenous vein, if
ultrasound shows evidence of venous reflux
Page 1 of 7
MEDICAL POLICY
No. 91326-R5
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal
Radiofrequency Ablation and Sclerotherapy
3. The following procedures are not covered as there is insufficient evidence to
conclude benefits and efficacy:
a. Transilluminated Powered Phlebectomy (TIPP)
b. ERFA and EVLT for accessory or perforator veins
c. Endomechanical or mechanochemical ablative approach (e.g., ClariVein™
Catheter)
4. Limitations:
a. Intra-operative ultrasound guidance is included as part of the surgical
procedure code(s) for ERFA and EVLT, and is not separately payable.
b. The treatment of asymptomatic varicose veins, or of symptomatic
varicose veins without a 3 month trial of conservative therapy, is not
covered.
c. The treatment of spider veins or superficial telangiectasis is considered
cosmetic, and therefore not covered, unless there is associated
bleeding.
d. Coverage is only for FDA devices specifically approved for these
procedures.
e. One pre-operative Doppler ultrasound study or duplex scan will be
covered.
f. Post-procedure Doppler ultrasound studies will be allowed if
medically necessary for continuing symptoms.
II.
MEDICAL NECESSITY REVIEW
Required
III.
Not Required
Not Applicable
APPLICATION TO PRODUCTS
Coverage is subject to member’s specific benefits. Group specific policy will
supersede this policy when applicable.
 HMO/EPO: This policy applies to insured HMO/EPO plans.
 POS: This policy applies to insured POS plans.
 PPO: This policy applies to insured PPO plans. Consult individual plan documents as
state mandated benefits may apply. If there is a conflict between this policy and a plan
document, the provisions of the plan document will govern.
 ASO: For self-funded plans, consult individual plan documents. If there is a conflict
between this policy and a self-funded plan document, the provisions of the plan document
will govern.
 INDIVIDUAL: For individual policies, consult the individual insurance policy. If there is
a conflict between this medical policy and the individual insurance policy document, the
provisions of the individual insurance policy will govern.
 MEDICARE: Coverage is determined by the Centers for Medicare and Medicaid Services
(CMS); if a coverage determination has not been adopted by CMS, this policy applies.
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MEDICAL POLICY
No. 91326-R5
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal
Radiofrequency Ablation and Sclerotherapy
 MEDICAID: For Medicaid members, this policy will apply. Coverage is based on medical
necessity criteria being met and the appropriate code(s) from the coding section of this
policy being included on the Michigan Medicaid Fee Schedule located at:
http://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546_42551-159815-,00.html. If there is a discrepancy between this policy and the Michigan Medicaid Provider
Manual located at: http://www.michigan.gov/mdch/0,1607,7-132-2945_5100-87572-,00.html, the Michigan Medicaid Provider Manual will govern. For Medical
Supplies/DME/Prosthetics and Orthotics, please refer to the Michigan Medicaid Fee
Schedule to verify coverage.
 MICHILD: For MICHILD members, this policy will apply unless MICHILD certificate of
coverage limits or extends coverage.
IV.
DESCRIPTION
Varicose veins are abnormally enlarged and tortuous vessels caused by
incompetent valves in the venous system that allow blood leakage or reflux.
They are the visible surface manifestation of an underlying syndrome of venous
insufficiency. Venous insufficiency syndromes allow venous blood to escape
from its normal flow path and flow in a retrograde direction down into an already
congested leg.
Mild forms of venous insufficiency are merely uncomfortable, annoying, or
cosmetically disfiguring. This condition can become clinically important when
symptoms such as cramping, throbbing, burning, swelling, feeling of heaviness or
fatigue, and alterations in skin pigmentation in the afflicted area become
pronounced. Severe varicosities may be associated with dermatitis, ulceration,
and thrombophlebitis.
First-line treatment of varicose veins includes conservative methods such as
exercise, weight reduction, elevation of the legs, avoidance of prolonged
immobility, or compression therapy. When these measures fail, medium to large
incompetent veins may be treated with surgical stripping, ligation, sclerotherapy,
endovenous laser therapy (EVLT), or endoluminal radiofrequency ablation
(ERFA). EVLT involves ultrasonography to evaluate the veins, infiltration of the
area to be treated with local anesthetic, and passage of an optical fiber into and
along the length of the Great Saphenous Vein (GSV) or Lesser Saphenous Vein
(LSV).
ERFA, (also known as VNUS® Closure System), delivers RF heat to the vein
causing contraction and occlusion.
Sclerotherapy is the injection of a chemical sclerosant into the affected vein wall
after it has been emptied of blood.
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MEDICAL POLICY
No. 91326-R5
V.
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal
Radiofrequency Ablation and Sclerotherapy
CODING INFORMATION
ICD-9 Codes that may apply (for dates of service on or before September 30, 2014):
451.0
Phlebitis and thrombophlebitis of superficial vessels of lower
extremities
451.2
Phlebitis and thrombophlebitis of lower extremities, unspecified
454.0 - 454.8
Varicose veins of lower extremities459.11 – 459.19 Postphlebitic
syndrome
459.31 – 459.39
Chronic venous hypertension (idiopathic)
459.81
Venous (Peripheral) Insufficiency, Unspecified
729.5
Pain in Limb
ICD-10 Codes that may apply (for dates of service on or after October 1, 2014):
I80.00 - I80.03
Phlebitis and thrombophlebitis of superficial vessels of lower
extremity
I80.3
Phlebitis and thrombophlebitis of lower extremities, unspecified
I83.001 – I83.029
I83.10 – I83.12
I83.201 - I83.229
I83.811 - I83.819
I83.891 - I83.899
I87.011 - I87.019
I87.021 - I87.029
I87.031 - I87.039
I87.091 - I87.099
I87.2
I87.311 - I87.319
I87.321 - I87.329
I87.331- I87.339
I87.391 - I87.399
I87.9
Varicose veins of lower extremity with ulcer
Varicose veins of lower extremity with inflammation
Varicose veins of lower extremity with both ulcer and
inflammation
Varicose veins of lower extremities with pain
Varicose veins of right lower extremities with other complications
Postthrombotic syndrome with ulcer of lower extremity
Postthrombotic syndrome with inflammation of lower extremity
Postthrombotic syndrome with ulcer and inflammation of lower
extremity
Postthrombotic syndrome with other complications of lower
extremity
Venous insufficiency (chronic) (peripheral)
Chronic venous hypertension (idiopathic) with ulcer of lower
extremity
Chronic venous hypertension (idiopathic) with inflammation of
lower extremity
Chronic venous hypertension (idiopathic) with ulcer and
inflammation of lower extremity
Chronic venous hypertension (idiopathic) with other complications
of lower extremity
Disorder of vein, unspecified
M79.604 – M79.609 Pain in limb (leg)
M79.661 - M79.669 Pain in lower leg
CPT/HCPCS Codes
76942
Ultrasonic Guidance for Needle Placement
93965
Noninvasive physiologic studies of extremity veins, complete bilateral study
(eg, Doppler waveform analysis with responses to compression and other
maneuvers, phleborheography, impedance plethysmography
93970
Duplex scan of extremity veins including responses to compression and other
maneuvers; complete bilateral study
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MEDICAL POLICY
No. 91326-R5
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal
Radiofrequency Ablation and Sclerotherapy
93971
Duplex scan of extremity veins including responses to compression and other
maneuvers; unilateral or limited study
36470
36471
Injection of sclerosing solution; single vein
Injection of sclerosing solution; multiple veins, same leg
36475
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all
imaging guidance and monitoring, percutaneous, radiofrequency; first vein
treated
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all
imaging guidance and monitoring, percutaneous, radiofrequency; second and
subsequent veins treated in a single extremity, each through separate access
sites (List separately in addition to code for primary procedure)
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all
imaging guidance and monitoring, percutaneous, laser; first vein treated
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all
imaging guidance and monitoring, percutaneous, laser; second and subsequent
veins treated in a single extremity, each through separate access sites (List
separately in addition to code for primary procedure)
Vascular endoscopy, surgical, with ligation of perforator veins, subfascial
(SEPS)
36476
36478
36479
37500
37700
37718
37722
37735
37760
37761
37765
37766
37780
37785
Ligation and division of long saphenous vein at saphenofemoral junction, or
distal interruptions
Ligation, division, and stripping, short saphenous vein
Ligation, division, and stripping, long (greater) saphenous veins from
saphenofemoral junction to knee or below
Ligation and division and complete stripping of long or short saphenous veins
with radical excision of ulcer and skin graft and/or interruption of
communicating veins of lower leg, with excision of deep fascia
Ligation of perforator veins, subfascial, radical (Linton type), with or without
skin graft, open
Ligation of perforator vein(s), subfascial, open, including ultrasound guidance,
when performed, 1 leg
Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions
Stab phlebectomy of varicose veins, one extremity; more than 20 incisions
division, and/or excision of varicose vein cluster(s), one leg
Ligation and division of short saphenous vein at saphenopopliteal junction
(separate procedure)
Ligation, division, and/or excision of varicose vein cluster(s), one leg
NOT COVERED Diagnoses
All general surgical services performed for these “Not Covered Diagnoses” will be
denied as not covered.
ICD-9 Codes that are not covered (for dates of service on or before September 30, 2014):
454.9
Asymptomatic varicose veins
V50.1
Other plastic surgery for unacceptable cosmetic appearance
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MEDICAL POLICY
No. 91326-R5
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal
Radiofrequency Ablation and Sclerotherapy
ICD-10 Codes that are not covered (for dates of service on or after October 1, 2014):
I83.90 – I83.93
Asymptomatic varicose veins of lower extremity
Z41.1
Encounter for cosmetic surgery
Not Covered Procedures
36468
Single or multiple injections of sclerosing solutions, spider veins
(telangiectasia); limb or trunk
36469
Single or multiple injections of sclerosing solutions, spider veins
(telangiectasia); face
37799
Unlisted procedure, vascular surgery - Not covered if billed for
Transilluminated Powered Phlebectomy. (Explanatory notes must accompany
claim)
S2202
Echosclerotherapy
Billed for endomechanical or mechanochemical ablative approach (e.g., ClariVein™
Catheter)”:
37204
Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve
hemostasis, to occlude a vascular malformation), percutaneous, any method,
non-central nervous system, non-head or neck
36011
Selective catheter placement, venous system; first order branch (eg, renal vein,
jugular vein)
75894
Transcatheter therapy, embolization, any method, radiological supervision and
interpretation
Special Notes: This policy was previously entitled “Sclerotherapy for Varicose Veins”
VI.
REFERENCES
“Transilluminated Powered Phlebectomy for Symptomatic Varicose Veins” HAYES, Inc.
May 2002 & Updated Search April 26, 2006.
“Endoluminal Radiofrequency Ablation for Varicose Veins of the Leg” HAYES, Inc.
May 2006.
“Endovenous Laser Therapy for Varicose Veins”, HAYES Inc., May 2003 & March
2009.
“Varicose Veins”, Aetna Clinical Policy Bulletin, No: 0050
http://www.aetna.com/cpb/data/CPBA0050.html (Retrieved August 15, 2006 ,
September 9, 2010 - September 14, 2012 & September 11, 2013).
“Plastic surgery”, Blue Cross Blue Shield of Massachusetts, Policy 68, August 2003.
http://www.bcbsma.com/common/en_US/medical_policies/fs068.htm (September
15, 2003).
“Varicose Veins”, eMedicine. Available on the World Wide Web @
http://www.emedicine.com/med/topic2788.htm (Retrieved August 24, 2006)
“The Treatment of Varicose Veins of the Lower Extremities”, Wisconsin Physicians
Service LCD. 02/16/2005.
“Varicose Vein Treatment” The Regence Group Medical Policy, 09/06/2005. Available
on the World Wide Web @
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MEDICAL POLICY
No. 91326-R5
VARICOSE VEIN TREATMENT:
Endovenous Laser Therapy, Endoluminal
Radiofrequency Ablation and Sclerotherapy
http://www.regence.com/trgmedpol/surgery/sur104.html (Retrieved August 15,
2006 & September 9, 2010)
“Varicose Vein Treatments” Cigna Healthcare Coverage Position @
http://www.cigna.com/health/provider/medical/procedural/coverage_positions/medi
cal/index.html (Retrieved August 15, 2006 , September 9, 2010, September 14,
2012 & September 11, 2013).
“Hayes , Inc. ClariVein® Occlusion Catheter, Non-Thermal Vein Ablation
System (Vascular Insights LLC) for Varicose Veins, Search & Summary,
April 2012”
AMA CPT Copyright Statement:
All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the
American Medical Association.
This document is for informational purposes only. It is not an authorization, certification, explanation of
benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage.
Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect
as of the date services are rendered. Priority Health’s medical policies are developed with the assistance
of medical professionals and are based upon a review of published and unpublished information including,
but not limited to, current medical literature, guidelines published by public health and health research
agencies, and community medical practices in the treatment and diagnosis of disease. Because medical
practice, information, and technology are constantly changing, Priority Health reserves the right to review
and update its medical policies at its discretion.
Priority Health’s medical policies are intended to serve as a resource to the plan. They are not intended to
limit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providers
are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels
of care and treatment they choose to provide.
The name “Priority Health” and the term “plan” mean Priority Health, Priority Health Managed Benefits,
Inc., Priority Health Insurance Company and Priority Health Government Programs, Inc.
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